Private Sector Engagement for Immunisation Programmes: A Pragmatic Scoping Review of 25 Years of Evidence on Good Practice in Low-Income and Middle-Income Countries

"This review identified emerging best practices that will be of interest to the wider immunisation community looking to engage more systematically with private sector providers to increase equitable immunisation coverage to improve health and well-being."

Recent analyses of the challenge posed by zero-dose children, who often inhabit environments characterised by economic, social, gender, and cultural disadvantages, highlight the importance of non-government providers in delivering immunisation. Non-state actor often have better access to or are preferred by vulnerable populations, such as those living in fragile and conflict-affected settings. In fact, private sector facilities - including faith-based organisations (FBOs) and non-governmental organisations (NGOs) - now provide a significant proportion of immunisation services across Africa, Asia, and Latin America and Caribbean countries. Given the increasing importance of PSE in vaccination, this review sought to identify gaps and to update and consolidate evidence on promising practices in PSE.

Building on two previous reviews published in 2011 and 2017, the researchers conducted a pragmatic scoping review of peer-reviewed articles from low- and middle-income countries (LMICs) published between September 2016 and November 2021. Ultimately, the review included over 80 well-documented analyses of PSE for vaccination, derived from 54 peer-reviewed publications from 1998 to 2016 included in prior reviews, 21 new publications from 24 countries published since 2016, and 1 new systematic review. The researchers extracted and analysed findings using an analytical framework covering motivations, enablers and barriers, risks and challenges, and engagement mechanisms.

The role of the private sector was widely seen as extending the reach and coverage of immunisation services to unreached communities. Depending on the LMIC, the level of PSE ranged from 3%-4% to over 60% of all childhood vaccinations. The researchers extracted information about reported underlying motivations, including perceived benefits, for private sector providers to participate in immunisation service delivery. These motivations included personal beliefs, ethics, financial incentives, non-financial rewards (awards, recognition), and opportunities to improve service quality or collaborate with the government on improvement efforts.

Promising practices for PSE included using governance and policy to leverage private providers' motivations and including them in programme efforts. Planning and monitoring efforts were effective when linked with regulatory requirements based on national standards for services, reporting, and performance monitoring. Information systems were effective when they included private sector services in vaccine monitoring and surveillance.

Both the earlier reviews, as well as additional examples from this updated scoping review, indicate that community and client preferences may provide an important enabler to private provision. Both access and trust were critical in conflict-affected Afghanistan, where clients trusted private providers more than the government to provide vaccination services. The one systematic review included in this updated review noted that pharmacists are often more trusted and more accessible than public sources, giving them an advantage in advocacy and promotion, and in 8 of 25 countries, in provision of vaccination services as well. A study of retail medicine outlets in western Kenya also emphasised the easy accessibility of local private chemists and pharmacies. Long wait times and vaccine stock-outs suppress demand for vaccination in most settings.

The limited examples of mechanisms of engagement in the published literature fell under three categories: formal public-private agreements or partnerships, contracting engagement with non-profit NGOs or FBOs, and engagement through professional associations and networks. Multiple studies highlighted potential roles for new partners. One study profiled the activities of the Indonesia Pediatric Society in vaccine promotion as one of nine LMICs involved in a global project to demonstrate potential roles for paediatric societies in vaccination efforts, including coordinating clinicians, advisors, educators, and advocates. In addition to professional societies,  FBO umbrella agencies may be appropriately positioned to support coordination, training, quality monitoring, recognition, and some system elements.

Risks and challenges of PSE identified in the review include compliance and reporting lapses on vaccination schedules, non-adherence to accreditation standards, missed opportunities for vaccinations, lack of awareness, limited training or systematic engagement opportunities, and additional administrative or service charges. Poor capture of information in public health information systems, especially for vaccination coverage, adverse events following immunisation (AEFIs), and notifiable diseases, poses challenges to effective PSE.

Future research implications include evaluations and research related to understanding the motivations of providers, expanding task-shifting models to pharmacies and community health workers, and testing innovative financing models.

Programmatic implications include using existing geospatial and other data to understand the role, scope, location and scale of private sector facilities offering routine immunisation services and leveraging those assets to permanently expand the reach and resources for routine immunisation and life-course vaccination.

Future policy recommendations to emerge from this study include facilitating policy dialogues with national stakeholders around PSE for immunisation service delivery and engaging with global immunisation partners and donors to update global guidance on PSE for immunisation.

In conclusion: "The published evidence captures numerous strategies to facilitate stronger immunisation programme engagement with the private sector. Stronger PSE can potentially reach zero-dose and underimmunised populations in low-resource settings and build resilient systems. Untapped opportunities exist for more structured testing of approaches to inform global guidance."